A Randomised Controlled Trial of a Brief Online Self-Help Mindfulness-Based Intervention

A Randomised Controlled Trial of a Brief Online Self-Help Mindfulness-Based Intervention:

Effects on Rumination and Worry

Kim Skerrett

Submitted for the Degree of

Doctor of Psychology

(Clinical Psychology)

School of Psychology

Faculty of Arts and Human Sciences

University of Surrey

Guildford, Surrey

United Kingdom

September 2015

Abstract

Objective: Mindfulness-based interventions (MBIs) such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) have been shown to be effective for reducing worry and rumination. Recently, brief MBIs have also been found to be beneficial for psychological wellbeing, and this includes some preliminary evidence for the use of brief, self-help MBIs delivered online. The current study aimed to assess the effect of a brief, online self-help MBI on worry and rumination, and assess the extent to which this effect was specific to MBIs.

Methods: A randomised controlled trial was conducted with 172 participants in a self-selected sample. Recruitment took place at a University campus and online via social networking websites. Participants were randomised to one of three groups (MBI, guided visual imagery (GVI) or wait-list control). Self-report measures of mindfulness, worry and rumination were completed at three time points (pre, post and one-week follow-up). Mediation analyses were performed using bootstrapping sampling procedures.

Results and conclusions: Both MBI and GVI groups brought about significant improvements in mindfulness skills, worry and rumination when compared to a wait-list control, and improvements in worry and rumination were mediated by mindfulness skills. There were no significant differences between the MBI and GVI groups on improvements in mindfulness, worry or rumination, although this may have been due to low power. Improvements in mindfulness skills consistently predicted reductions in rumination and worry. The lack of significant difference between MBI and GVI might be explained by a lack of power, expectancy effects, or unforeseen overlaps in mechanisms between GVI and mindfulness.

Acknowledgements

My sincere thanks goes to my research supervisors Dr Clara Strauss and Dr Lyn Ellett, who provided expert support and guidance throughout the various stages of this project. They have been supportive and generous with their time and feedback, and this project would not have been possible without them. I would also like to thank Dr Kate Gleeson, who provided invaluable University-based support in times of need, and my research partner Robert Shore, a fellow Trainee Clinical Psychologist at the University of Surrey. Robert and I shared all aspects of the recruitment and data collection process, including the creation and administration of the online questionnaires and interventions. My thanks goes to friends and colleagues who assisted in the recruitment process by sharing the link via social networking sites and emails, as well as the many participants who took their time to complete the questionnaires and engage in daily practice at home.

Training has been a challenging experience and it would not have been possible without the support of my friends and family. In particular I would like to thank my fiancé Sam, who has stayed by my side and has been my rock over the three years of completing my doctorate. I would also like to thank my clinical tutor Nan Holmes for all of her help and support in completing my clinical placements.

Contents Page

MRP EMPIRICAL PAPER 6

Abstract 7

Introduction 8

Method 18

Results 28

Discussion 39

References 49

List of MRP Empirical Paper Appendices 60

MRP Empirical Paper Appendices 61

MRP PROPOSAL 111

Introduction 112

Research Question 114

Main Hypotheses 114

Method 117

Ethical considerations 121

R&D Considerations 122

Proposed Data Analysis 122

Service User and Carer Consultation / Involvement 123

Feasibility Issues 123

Dissemination strategy 124

References 126

LITERATURE REVIEW 132

Abstract 133

Introduction 134

Method 140

Results 145

Discussion 152

References 161

CLINICAL EXPERIENCE 170

ASSESSMENTS 172

MRP EMPIRICAL PAPER

PsychD Clinical Psychology

The University of Surrey

Major Research Project

A Randomised Controlled Trial of a Brief Online Self-Help Mindfulness-Based Intervention: Effects on Rumination and Worry

Kim Skerrett

Word Count: 9,979 not including abstract, acknowledgements, tables, references and appendices

Abstract

Introduction

Mindfulness

Mindfulness-based interventions (MBIs) are psychological interventions based on Buddhist mindfulness practice and principles and are typically delivered in groups. The key principles of mindfulness include drawing one’s attention to the present-moment, whilst remaining open and non-judgemental (Kabat-Zinn, 1990). The most commonly used MBI programs are the eight-session group interventions mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990) and mindfulness-based cognitive therapy (MBCT; Segal, Williams & Teasdale, 2002).

Several meta-analyses have been conducted into the effectiveness of MBIs for depression, anxiety and stress; however many of these included studies with uncontrolled single-group designs. More recently, meta-analyses including randomised controlled trials (RCTs) only have been conducted, offering more convincing and robust evidence for the effectiveness of MBIs. For example, Fjorback, Arendt, Ørnbøl, Fink and Walach (2011) conducted a systematic review including only RCTS of standard MBSR or MBCT. The review included 21 studies (four non-clinical, eleven with somatic conditions, and six with psychiatric disorders). They found that MBSR was beneficial for improving mental health and reducing symptoms of stress, anxiety and depression, as well as improving quality of life and medical disease management in those with long-term conditions in comparison to control conditions, and that MBCT reduced the risk of depressive relapse in patients with three or more previous episodes of depression. However, they also found that MBCT may increase the risk of relapse in those with only two previous episodes. Piet and Hougard (2011) conducted a meta-analysis of six RCTs investigating the relapse prevention potential of MBCT for recurrent depression. They found that on average MBCT reduced the risk of depressive relapse over a period of 14-18 months by 43% when compared to treatment-as-usual (TAU) or to placebo for participants that had experienced three or more episodes of depression. More recently, Strauss, Cavanagh, Oliver and Pettman (2014) conducted a meta-analysis of RCTS (12 studies) including participants who met diagnostic criteria for anxiety and depression. Overall, they found significant post-intervention between-group benefits of MBIs relative to control conditions on primary symptom severity (Hedges g=-0.59, 95% CI = −0.12, −1.06). Significant effects were observed for depressive symptoms (g=-0.73, 95% CI = −0.09, −1.36) but not anxiety symptoms (g= .0.55, 95% CI = 0.09, −1.18). However this may have been due to a lack of power for the analysis, and a range of different anxiety disorders included in the review, which may be too heterogeneous to draw overall conclusions about anxiety. In their meta-analysis, significant effects were found when MBIs were compared to inactive controls (g=-1.03, 95% CI = −0.40, −1.66) but not active controls such as group CBT (g=0.03, 95% CI = 0.54, −0.48), suggesting that MBIs may be similar in effectiveness to existing treatments such as group CBT.

The above meta-analyses provide strong evidence that standard MBIs such as MBCT and MBSR are effective at targeting symptoms of depression, stress and anxiety (though possibly not for all anxiety disorders), and for relapse prevention in recurrent depression for people with a history of three or more episodes. Standard length MBCT and MBSR programs consist of eight weekly two to three hour group sessions, a full-day retreat, and up to forty minutes of home practice six days per week. This requires a large time commitment from participants and may pose a barrier to engagement for some groups (Carmody & Baer, 2009) as well as resource demands for many public health services. However, there is evidence that MBIs involving fewer sessions, and shorter meditation practices (potentially being more accessible), can also bring about positive effects. Jain et al. (2007) used a shortened MBSR program which consisted of four ninety-minute sessions and a six-hour retreat, compared to a wait-list control with a non-clinical student population. They found large post-intervention between-group effect-sizes for distress (d=1.36), positive states of mind (d=0.71) and rumination (d=2.75). Call, Miron and Orcutt (2013) evaluated a three weekly 45 minute mindfulness-based group intervention with a student sample. They included only those who had scored 45 or higher (moderate) on the Penn State Worry Questionnaire and 62% of their sample scored 58 or higher, indicating clinical symptomology. They found small to medium pre-to-post effect-sizes for anxiety (d=0.27) and stress (d=0.56). Zeidan, Johnson, Gordon and Goolkasian (2010) used three daily twenty-minute group sessions of small-group mindfulness training with a student sample, and found significantly greater reductions in negative mood and heart rate for those in the intervention condition compared to a ‘sham meditation’ control condition (d=0.81). Furthermore, a systematic review found no relationship between the length of MBSR programs and outcomes for psychological distress (Carmody & Baer, 2009). This all suggests that briefer MBIs than the standard length MBCT/MBSR may offer similar benefits to the full eight-week program, at least in non-clinical populations.

Not only is there evidence to support the effectiveness of brief MBIs with face-to-face teacher contact, there is growing evidence for the effectiveness of brief self-help MBIs. A randomised controlled trial (RCT) by Cavanagh et al. (2013) used a two-week online self-help mindfulness intervention, in which students were provided with written information on mindfulness and were instructed to listen to a mindfulness practice for ten minutes per day. Significant group-by-time interactions demonstrated that the MBI was effective for increasing mindfulness (d=0.42) and reducing perceived stress (d=0.62) and anxiety and depression (d=0.41) when compared to a wait list control. A meta-analysis of fifteen randomised controlled trials (RCTs) of mindfulness and acceptance-based self-help interventions by Cavanagh, Strauss, Forder and Jones (2014) showed a medium post-intervention between-group effect size for increased mindfulness and acceptance (g=0.49, 95% CI = 0.23, 0.76), and a small to medium effect size for both depression (g=-0.37, 95% CI = -0.56, 0.18) and anxiety symptoms (g=-0.33, 95% CI = 0.56, 0.10) compared to controls. These findings suggest that MBIs delivered with minimal therapist resources may still bring about positive changes to mental health.

Although the effectiveness of MBIs, including the standard 8-week courses, briefer courses and self-help, for a range of psychological difficulties is well established, less is known about the mechanisms by which MBIs bring about change. Some mechanisms have been proposed in the current literature, such as increased self-compassion (Keng, Smoski, Robins, Ekblad & Brantley, 2012; Holzel et al., 2011); increased meta-cognitive awareness (Teasdale et al., 2002); attention regulation (Holzel et al., 2011); de-centering (Feldman, Greeson & Senville, 2010); emotional regulation (Holzel et al., 2011) and reductions in repetitive thinking such as rumination (Deyo, Wilson, Ong & Koopman, 2009). The current study will focus on repetitive negative thinking, in particular worry and rumination. This is because MBCT in particular is theorised to work by reducing rumination in people with recurrent depression (Segal et al., 2002; Ma & Teasdale, 2004; Hereen & Philippot, 2011). MBSR has also been investigated in terms of its clinical application to rumination and depressive relapse (Deyo et al. 2009).

Rumination, Worry, and Repetitive Negative Thought

Rumination can be defined as a style of repetitive thinking that is negative and self-focused (Treynor, Gonzelz & Nolen-Hoeksema, 2003). Rumination focuses the individual’s awareness on current emotional states and past negative events and it has been found to be strongly related to depression (Nolen-Hoeksema, 1991). Worry is another style of repetitive negative thinking that is focused on anticipated future events that are perceived as threatening to the individual’s sense of security or safety. According to the DSM-V, worry is a key feature of Generalised Anxiety Disorder (American Psychiatric Association, 2013).

Segerstrom et al. (2003) defined “repetitive thought” (RT), as a “process of thinking attentively, repetitively or frequently about one’s self and one’s world,” (p. 909). The authors described different types of RT, with some identified as maladaptive (negative RT such as rumination and worry) and some seen as more adaptive (coping strategies such as emotional processing and reflection). They argued for a general tendency towards RT, with the various forms representing distinct but overlapping constructs. In an extensive review of various forms of RT (Watkins, 2008) it was argued that rumination and worry have similar negative consequences, but are often investigated separately in the research literature due to arising in different clinical domains (rumination being associated with depression, and worry with anxiety). This means that the similarities between the two constructs are often overlooked. However, Fresco, Frankel, Mennin, Turk and Heimberg (2002) carried out a factor analysis and found that rumination and worry have similar associations with anxiety (worry r =.30, dwelling r = .39) and depression (worry r=.42, dwelling r=.42). McEvoy et al. (2013) conducted a cross-sectional study of patients with depression and anxiety disorders at a community mental health clinic and found that repetitive negative thinking (RNT) did not differ across the different diagnosis groups, and that higher levels of RNT were associated with higher comorbidity. They therefore argued for RNT as a trans-diagnostic construct across a range of depression and anxiety disorders.